Faculty Bibliography

This document is a focused update to the 2017 colorectal cancer (CRC) screening recommendations from the U.S. Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. This update is restricted to addressing the age to start and stop CRC screening in average-risk individuals and the recommended screening modalities. Although there is no literature demonstrating that CRC screening in individuals under age 50 improves health outcomes such as CRC incidence or CRC-related mortality, sufficient data support the U.S. Multi-Society Task Force to suggest average-risk CRC screening begin at age 45. This recommendation is based on the increasing disease burden among individuals under age 50, emerging data that the prevalence of advanced colorectal neoplasia in individuals ages 45 to 49 approaches rates in individuals 50 to 59, and modeling studies that demonstrate the benefits of screening outweigh the potential harms and costs. For individuals ages 76 to 85, the decision to start or continue screening should be individualized and based on prior screening history, life expectancy, CRC risk, and personal preference. Screening is not recommended after age 85.

This document is a focused update to the 2017 colorectal cancer (CRC) screening recommendations from the U.S. Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. This update is restricted to addressing the age to start and stop CRC screening in average-risk individuals and the recommended screening modalities. Although there is no literature demonstrating that CRC screening in individuals under age 50 improves health outcomes such as CRC incidence or CRC-related mortality, sufficient data support the U.S. Multi-Society Task Force to suggest average-risk CRC screening begin at age 45. This recommendation is based on the increasing disease burden among individuals under age 50, emerging data that the prevalence of advanced colorectal neoplasia in individuals ages 45 to 49 approaches rates in individuals 50 to 59, and modeling studies that demonstrate the benefits of screening outweigh the potential harms and costs. For individuals ages 76 to 85, the decision to start or continue screening should be individualized and based on prior screening history, life expectancy, CRC risk, and personal preference. Screening is not recommended after age 85.

This document is a focused update to the 2017 colorectal cancer (CRC) screening recommendations from the U.S. Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. This update is restricted to addressing the age to start and stop CRC screening in average-risk individuals and the recommended screening modalities. Although there is no literature demonstrating that CRC screening in individuals under age 50 improves health outcomes such as CRC incidence or CRC-related mortality, sufficient data support the U.S. Multi-Society Task Force to suggest average-risk CRC screening begin at age 45. This recommendation is based on the increasing disease burden among individuals under age 50, emerging data that the prevalence of advanced colorectal neoplasia in individuals ages 45 to 49 approaches rates in individuals 50 to 59, and modeling studies that demonstrate the benefits of screening outweigh the potential harms and costs. For individuals ages 76 to 85, the decision to start or continue screening should be individualized and based on prior screening history, life expectancy, CRC risk, and personal preference. Screening is not recommended after age 85.

Introduction: Combination endoscopic therapy is considered a gold standard treatment of upper gastrointestinal bleeding (UGIB). Endoscopic therapy reduces mortality in these patients. Hemospray is a haemostatic powder used for the endoscopic treatment of GI bleeds. We aimed to analyse the outcomes of Hemospray therapy in combination with standard endoscopic treatments. Aims & Methods: Data was collected on consecutive patients with GIB's and treated with Hemospray as part of a combination with standard endoscopic treatments from 18 centres (USA, UK, France, Germany, Spain). The decision to use Hemospray and what combination to use was at the discretion of the endoscopist.
Result(s): We analysed the outcomes of 230 patients (UGIB's - 134 peptic ulcers, 37 post endoscopic therapy, 29 UGI malignancies, 7 variceal, 6 angiodysplasia, 2 inflammation, 15 lower GI bleeds) (Table 1). 134/267 (50%) of the peptic ulcer cohort were treated with Hemospray combination therapy. Haemostasis rates of 92% were achieved relative to 89% in the overall peptic ulcer bleed cohort. 20/108 (19%) had a rebleed and 30-day mortality of 17% (20/119). The most common combination therapy was Hemospray with adrenaline injection therapy with a haemostasis rate of 93% (49/53). Hemospray was used as a second modality in 36/66 (55%) cases. In the remaining cases it was used as a 3rd modality, and a 4thmodality in one case. 58% of all patients had Forrest 1b ulcers where a haemostasis rate of 91% was achieved, re-bleeding in 12/69 (17%). 18% of patients had Forrest 1a ulcers with immediate haemostasis in 21/24 (88%) patients, re-bleed in 4/18 (22%) patients. In the post endoscopic therapy cohort, a 100% haemostasis rate was achieved with a 4% (1/26) re-bleed. Most of the cases were post endoscopic mucosal resection (22/37, 59%). The most common combination therapy was Hemospray and adrenaline injection (24% of patients). In malignancy related UGIB's an 86% (25/29) haemostasis rate was achieved, with a rebleed rate of 17% (4/23). The most common combination was Hemospray and adrenaline injection therapy (12/29, 41%) where a 92% haemostasis rate was achieved and one re-bleed. In variceal bleeds (5 oesophageal, 2 gastric) a haemostasis rate of 86% (6/7) was achieved, a rebleed rate of 29%. Hemospray was used as the second modality to banding/glue injection in the majority of cases.
Conclusion(s): High haemostasis rates were achieved following treatment with Hemospray in all the subgroups. In peptic ulcers high haemostasis and reasonable re-bleeding rates were achieved in Forrest 1a/1b ulcers. Results show that Hemospray combination therapy can have a role in lower GI bleeds. There is a shift towards use of Hemospray as part of standard combination therapy. Its role needs to be clearly defined within the GI bleed algorithm. Disclosure: M.H - Speaker fees (Cook Medical), R.H - Received research grant support from Pentax Medical, Cook Endoscopy, Fractyl Ltd, C2 therapeutics and Medtronic to support research infrastructure

We describe 2 cases in which video capsule endoscopy was performed remotely using TeleInGEstion Remote Video Capsule Endoscopy (TIGER VCE), given limited access to endoscopy during the COVID-19 pandemic. The patients ingested the CapsoCam capsule during a televisit, and the video was subsequently reviewed remotely by the physician. TIGER VCE was used to diagnose a benign etiology of melena and used to confirm a diagnosis of Crohn's disease before the initiation of biologic therapy. These cases demonstrate the safety and efficacy of TIGER VCE. We feel that this technique may be considered as a standard ingestion technique in the future.

Introduction: Multiple recent outbreaks of multidrug resistant organisms (MDRO) related to contaminated duodenoscopes have led to increased scrutiny of duodenoscope standard reprocessing methods. A key component of duodenoscope reprocessing is the cleaning step that occurs before high-level disinfection (HLD) or sterilization. Perfect adherence to manufacturer Instructions for Use (IFU) for manual cleaning can be difficult to achieve due to technical complexity and is open to human factor error. Adequate cleaning is measured against FDA and industry maximum allowed contaminants post cleaning of protein<6.4 ug/cm^2 and carbohydrates<2.2 ug/cm^2. Inadequate cleaning increases the risk for inadequate high-level disinfection and the possibility of procedures being performed with contaminated duodenoscopes. A new cleaning process has been developed to fully automate the cleaning step using turbulent flow technology.
Method(s): A total of 48 therapeutic ERCP procedures were performed utilizing Olympus TJF-Q180V duodenoscopes. After bedside point of use cleaning, 21 duodenoscopes were manually cleaned by trained technicians following the manufacturer IFU. 27 duodenoscopes were cleaned using the automated cleaning system. Duodenoscope instrument channels and distal elevator areas were sampled for residual protein and carbohydrates after cleaning.
Result(s): The automated cleaning process resulted in a lower average level of residual protein and carbohydrate compared to standard manual cleaning (Table 1). Using FDA and industry standards as a benchmark, the automated cleaning process reduced levels of protein and carbohydrate below safety threshold levels on all study duodenoscopes, while manual cleaning resulted in 4/21 (19%) duodenoscopes having protein or carbohydrate levels above FDA standards (p= 0.03).
Conclusion(s): Recent outbreaks of MDRO organisms transmitted after ERCP have brought to light the risk to patients when reusable duodenoscopes are not sufficiently reprocessed. The complex design of the device-involving multiple channels and an elevator mechanism at the distal tip-makes proper cleaning difficult. Without sufficient cleaning, subsequent HLD or sterilization can fail to adequately remove contaminants. As seen in this study, manual cleaning can be prone to error. With no incidents of elevated bioburden post cleaning, a fully automated cleaning technology appears to be a viable alternative for replacement of manual cleaning of duodenoscopes

Introduction: Endoscopic ultrasound (EUS with fine needle aspiration (FNA) is often used to evaluate solid tumors of the pancreas. However, fine needle biopsy (FNB) offers a histologic sample versus a disaggregated sample seen in FNA. Even with FNB technique can limit sample quality. All current needles are manually operated. However, there is a novel motorized FNB needle offering a rotational axial motion resulting in an intact core. This case demonstrates the use of a motorized FNB needle for tissue sampling during EUS. Case Description/Methods: A 87 F presents for the work up of abdominal pain and weight loss. She has no significant medical problems. A cat scan of the abdomen and pelvis was ordered revealing a 3.5 cm mass in the body of the pancreas, concerning for neoplasm. The patient was sent for EUS with biopsy for tissue diagnosis. During the EUS exam a 19g motorized FNB needle was used. After the needle is passed into the tumor a button on the needle shaft is pressed. The needle begins to rotate using an electro mechanical axial motion cutting into the tumor to obtain a specimen. A single pass was required, which confirmed a ductal adenocarcinoma of the pancreas. Due to the vascular invasion the patient was sent to oncology for further management.
Discussion(s): Cancer management continuous to move in the direction of precision medicine. A tissue biopsy is needed to have intact histology sample for diagnosis of a malignant tumor. Furthermore, biopsy is needed to allow molecular analysis of the tumor to offer a personalized treatment plan. This is the first reported case of a motorized EUS needle for tissue acquisition. Future studies are needed to assess performance against traditional manual EUS needles

Introduction Dual endoscopic therapy has been considered the standard of care for endoscopic management of GI bleeding. We aimed to look at the outcomes of Hemospray as a monotherapy treatment for GI bleeds. Methods Data was collected on patients with GI bleeds treated with Hemospray monotherapy in 18 centres. Haemostasis was defined as cessation of bleeding within 5 minutes of hemospray application. Results 62 patients with peptic ulcer bleeds were treated. There was an immediate haemostasis of 90% (56/62), re-bleed rate of 16% (7/44) (Table 1). 69% were Forrest 1a/1b ulcers. 72 patients with malignancy related bleeds. There was a haemostasis rate of 100% and a re-bleed rate of 18% (11/63). There was a haemostasis rate of 100% with post endoscopic therapy bleeds. 48% were post endoscopic mucosal resection. 22 patients with lower GI bleeds were treated. 36% secondary to colonic tumours. There was a haemostasis rate of 96% (21/22) and re-bleed of 26% (5/19). A 100% haemostasis was achieved in 5 patients treated for gastric angiodysplasia with one re-bleed. Conclusions Results show high haemostasis and comparable rebleed rates with Hemospray monotherapy treatment. It may play a potential role in actively bleeding peptic ulcers in difficult anatomical positions to help bridge towards definitive therapy. These data may represent the evolution of new treatment paradigms as experience with haemostatic powders increases

Introduction: Missed adenomas during screening and surveillance colonoscopy are considered a leading cause of interval colorectal cancer (CRC). Numerous technologies were developed to assist in visualization of the mucosal surface and particularly the proximal aspect of haustral folds, consisting of either rear-viewing optics or mechanical manipulation of colon folds. Recent studies demonstrate superiority in increasing adenoma detection rate (ADR) of mechanical fold manipulation over rearview optical visualization, by two mechanical attachments at the distal tip of the colonoscope (Figure 1) - the Endocuff Vision single-use disposable attachment (ECV, Olympus Corporation, Japan) and the G-EYE permanently-mounted reusable and reprocessable balloon (G-EYE, Smart Medical Systems, Israel). The ECV is placed on the colonoscope tip prior to insertion, and is designed to expand radially during withdrawal, thereby allowing manipulation of folds. The G-EYE balloon is deflated during insertion, inflated at the cecum, engaging the colon wall and flattening colon folds during withdrawal, while centralizing colonoscopic view.
Method(s): Randomized, prospective, multicenter study, patients referred to screening or surveillance colonoscopy were randomized to undergo either ECV or G-EYE colonoscopy. A 1:1 randomization ratio between ECV and G-EYE colonoscopy was done. Polyps were removed, sent for pathology and analyzed, to determine the adenoma detection rate (ADR) and adenoma per patient (APP) in each group.
Result(s): 727 enrolled patients out of planned 970 (485 in each group) are presented (Table 1), 364 in the ECV group and 363 in the G-EYE group. Patient characteristics were similar in both groups. Withdrawal times were above the recommended 6-minute guideline threshold and similar in both arms. ADR in the G-EYE arm was 9.8% higher (relative increase 19.1%) than in the ECV arm, and the detection of advanced adenomas was doubled (24% versus 12%). The number of adenomas per patient was significantly higher for G-EYE colonoscopy, particularly the number of advanced and large adenomas.
Conclusion(s): This randomized trial is the first head to head comparison of these mechanical enhancement colonoscopy devices. In this present study G-EYE (preliminary analysis) demonstrated meaningful increase in ADR over ECV, particularly for advanced adenomas, as well as substantial increase in APP